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VERIFICATION OF RESTROOM FACILITY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> Vehicle Name(DBA): <br /> Address for Vehicle: <br /> Street Address p =yIp <br /> Q <br /> 1) License Plate#: $ L 11 Z f O 4) Year: 7 �� <br /> 2) Vehicle Vin#: I (;-!I H 1 5) Make/Model: <br /> 3) State Decal #: 3 a y 6 t 6) Color: U t+-1 r o � <br /> Name: <br /> .Wrl ti. <br /> Address of Owner: O 1" <br /> Street Address city Zip <br /> Mobile food facilities shall be operated within 200 feet of approved and readily available toilet and hand <br /> washing facilities. This is to ensure restroom facilities are available to employees whenever the mobile <br /> food facility is stopped to conduct business. CalCode Section 114315. <br /> I have access to the restroom facilities at the following business during my business hours and I am <br /> parked less than 200 feet away from the resttoom facilities. I will be responsible for maintaining the <br /> restroom in a clean and sanitary condition. <br /> g:2 iyl / <br /> Si afore o cle Operator Date <br /> Business Name: nIL d , <br /> Owner Name: \Z 1,"Y' <br /> Site Address: 2 2 C, r C- Ayk,A`5"' S 4--o C V <br /> Street Address city Zip <br /> Phone: `L U ri (� <br /> I,the business owner/operator,can and will provide the necessary restroom facilities for the operators of <br /> the above-mentioned vehicle at my business and I understand that the restroom facilities are subject to <br /> Environmental Health Department inspection. <br /> Signature Business owner/Operator Date <br /> EHD 16-017 Page 6 of 6 <br /> 8/4/2006 MFPU APPLICATION <br />